There are no secrets to success. It is the result of preparation, hard work, and learning from failure. - Colin Powell

Transcription

1 Fiona 18 December 2018 There are no secrets to success. It is the result of preparation, hard work, and learning from failure. - Colin Powell As this semester comes to an end, and as I approach the end of my writing experience for this class, I can reflect back and say I am proud of what I have accomplished. The research I have done, the facts I have gathered, and the paper I have written really allowed me to gain a great learning experience. This research and writing experience, I realized, can go far beyond just this class. The skill set I gained throughout the course of this semester can be applied when I am working in any field or on any project. This experience has taught me that in order to be successful and have a final product worth reading, perseverance and learning from times of failure or frustration must be had. As I have seen my work and research from the entire semester finally come together, I feel a great sense of accomplishment. Research is to see what everybody else has seen, and to think what nobody else has thought. - Albert Szent-Gyorgyi This quote by Gyorgyi relates to not only classes of a scientific disciple, but to all academic disciplines and to all ways of thinking. Without proper research, there is no way to fully understand or comprehend a certain issue at hand. Finding a topic of interest, looking into that topic, asking questions, obtaining the answers to those questions, and developing a unique way of thinking about the information and issue that nobody else has is perhaps the greatest learning opportunity one can experience.

2 My name is Fiona. I grew up and still live in Staten Island, NY. I attended Wagner College, which is also located in Staten Island, where I completed my undergraduate degree. I graduated from Wagner with my B.S. in Chemistry and Biology minor in I am now in my second year of studying dental hygiene at NYU. I am currently enrolled in the 3-year AAS Dental Hygiene program. I decided to do the 3-year program as opposed to the 2-year program due to the fact that it involves a lighter schedule load, which allows me to work more. I have been working at a private practice orthodontic office for the past 2 years. At my job I mainly do infection control, as well as work alongside the doctor to help assist with suctioning, completing orthodontic photos and x-rays, and giving instructions and guidance to the patients on how to properly care for their braces and oral health. Since I have been involved in the dental field for the past 2 years, and because I am pursuing a degree in dental hygiene, I felt that the topic of whether or not fluoride in drinking water is safe for people from different regions would be an interesting, yet challenging one for me to explore and analyze. The reason why I feel that this topic may be a challenge for me, personally, is because in the dental field fluoride is very commonly used as part of the patients treatments. However, because of my background in biology and chemistry, I feel that there are precautions that should be taken when using fluoride for patient care because of the fact that there are studies that discuss how fluoride, especially the fluoride that is found in drinking water, may have potential risks to people who are exposed to high levels of it. I am going to explore this controversial question to see if there is a potential risk in high levels of fluoride in drinking water, and if risks are being found, is it then safe to be using fluoride as a treatment for patients teeth. In developing regions of the world, such as certain areas of Bangladesh and India, the levels of fluoride in the drinking water are higher than what is regulated by the World Health

3 Organization. In more advanced regions, such as New York, the levels of fluoride added to the drinking water is regulated by the WHO. However, it may still not be safe to intake so much of it being that one can get the accurate amount of fluoride intake through treatment from their dentist, as well as from toothpastes and mouthwashes that have fluoride in them. The reason why fluoride is used on patients in dental practices and why it is added to drinking water is because it is believed to help protect the teeth and to prevent tooth decay. However, this practice of adding fluoride to drinking water as a method to help prevent tooth decay has remained a controversial topic since One quote that stood out to me in Paul Kalanithi s When Breath Becomes Air was Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete. I believe this quote can apply to any area of study or examination for any discipline. I feel that this quote is important to look towards and take into consideration when evaluating and determining a solution to a problem, because it always seems that the information and knowledge we gain as a population and as a community is not due to one person, one scientist, or one health care professional; but rather is a collective effort of all people working together to solve a common problem. And even then, a definite solution to some problems cannot be solved. With my investigation of whether or not this practice of adding fluoride to drinking water and the practice of using fluoride on patients to prevent certain dental complications from happening, I do not plan on coming up with a solution that would solve a controversial topic and problem that has been ongoing many decades, but rather look at the information available on this topic, and then come up with my own theories and hypotheses of what may come in the future if we continue to implement these practices and maybe think of another possible solution that can be implemented to begin to fix these issues.

4 Treat the Earth and all that dwell thereon with respect Remain close to the Great Spirit Show great respect for your fellow beings Work together for the benefit of all humankind Give assistance and kindness wherever needed Do what you know to be right Look after the well-being of mind and body Dedicate a share of your efforts to the greater good Be truthful and honest at all times Take full responsibility for your actions - Ten Commandments II I find this second part of the Native American Ten Commandments to be strongly correlated to many issues that we find prevalent in today s world. The problems and attention that this literary work brings forth are of great importance, and when fully analyzed, can be very mind-opening when looked at alongside an actual issue that needs to be solved. One very controversial issue in our world today is whether or not the practice of adding fluoride to drinking water in certain regions is safe. The reason why this is so controversial is because in certain regions of Bangladesh and neighboring areas of India, groundwater that contains elements, such as arsenic and fluoride presents serious issues for the people and environment. This is a recent issue specifically in the Eastern Regions of Bangladesh, since this area has been

5 having much fluoride contamination and has had fluorosis effects on many people living in this region. If the elements of arsenic and fluoride are causing harm in developing regions of the world, then why does the World Health Organization allow the addition of certain elements into the drinking water of other regions, for example the addition of fluoride in New York drinking water. This poetic work will be a great source to refer back to when trying to analyze, research, and determine possible solutions to this problem, due to the fact that there is a positive message and a common goal that is being communicated. The reason I am so passionate about this topic is due to two main reasons. One reason is because I am pursuing a career in dental hygiene, and since I will be practicing as a licensed clinician in the dental field in a few short years, I would like to educate myself as fully as possible on the risks of using fluoride. Although I am now in classes, such as clinic, that explicitly educates me on various procedures, techniques, and materials that I will be using in this field, I also like to further educate myself by doing my own studying and research when certain topics spark my interest. I developed this method of studying through further research back in my undergrad, and have continued to stick with it because I feel that I am providing myself with a deeper understanding. I would like to fully know, especially when being a health care provider to others in the future, what risks I may be exposing a patient to, aside from certain risks that are already accounted for as norms in this field. The other reason that I feel especially passionate about this topic is because towards the end of my senior year as an undergraduate student, I helped one of my professors do some research and study the fluoride in groundwater in different regions of the world. My professor, Dr. Alauddin, really helped me to gain a deep understanding of chemistry from a research standpoint. Dr. Alauddin is originally from Bangladesh, and some of his family still lives there. I had the pleasure of meeting his daughter

6 who was also born there. He was personally affected by the findings in some of our research due to the fact that some of his friends and family live there. When he asked for me to be a part of this project, I was instantly eager to begin. This was not only one of the first opportunities I had to do research with real life, attainable data, but one that I felt good about doing because the information and data attained would be used to solve real life worldly problems. Although I helped to analyze water samples taken from these regions, and assisted in computing and determining results, I was not able to fully look into these results on a larger scale and infer how serious this issue was, how the people in those regions were affected, and possible solutions that could be offered to help since I graduated before any more research and problem solving could be achieved on my end. I am taking my interest and passion for dental hygiene and integrating it with my chemistry and biochemistry background to analyze the problems and risks fluoride presents to those exposed to it. I plan to research why groundwater in different regions have higher levels of fluoride, to determine if fluoride is safe to be added to drinking water in more advanced regions, such as New York, and to deduce if it can pose a potential risk by being utilized in the dental field. The issue of whether or not fluoride provides a huge risk to those who intake this element has been a very controversial topic since The first occurence of adding fluoride to drinking water was done in 1945 in the Grand Rapids, Michigan. The idea behind adding fluoride to drinking water is because fluoride is believed to prevent cavities and dental diseases. Some claim it does little or nothing to prevent tooth decay and is dangerous for health. Others, including most dentists and public health officials, say it significantly lowers rates of tooth decay and presents no important health risks. (Hileman, 2006) Although this topic of dispute has been

7 a prevalent one for the past 70 plus years, there is still not that much research being done, tests being ran, and samples being pulled from various regions to determine exactly how serious and dangerous some fluoride levels can be. The main reason why this topic is one that is constantly up for dispute is because many people do not understand the information, facts, and research that has been done on fluoride. Many times people believe sources that are not always credible and misinterpret what they read and hear about this subject. According to the National Center for Biotechnology Information Problems include identifying benefits and harms, whether fluoride is a medicine, and the ethical implications. (Cheng, 2007) I think that if we as a society, and even myself when I become a licensed healthcare provider, better educate the public about fluoride, its advantages and disadvantages, its risks and benefits, then there would be less dispute and more of a complete understanding. In light of the poetic work Ten Commandments II, a point that seems to be frequently stressed is the idea that we should all hold in high regards the well-being and benefit of humankind and do what is best for the greater good. The question of Is it right that this practice of adding fluoride to drinking water should be done when the public has not given consent and do not have a say whether or not they want to intake this element? is one that is the most debatable and frequently asked, however is yet to be resolved. The reason why this question, specifically, brings forth much controversy is because many people believe that this practice of adding fluoride without their consent is not only unfair, but is unethical and wrong. Many people believe this practice is not beneficial and is not done with the greater good of people in mind. Through further extensive research that is to follow, I will be attempting to provide an answer to this question and a solution to this problem as a whole.

8 Science is a way of life. Science is a perspective. Science is the process that takes us from confusion to understanding in a manner that's precise, predictive and reliable - a transformation, for those lucky enough to experience it, that is empowering and emotional. - Brian Greene There is no way to establish a solution to a given problem without proper understanding of the issue at hand and without appropriate information and research to resolve said issue. By implementing research, tests and results, and analysis of the results; a solution to the issue of fluoridation of groundwater can potentially be solved in the future. Through my own personal research, I found that by examining water samples that were taken from Bangladesh to be a very helpful, insightful, and crucial aspect when analyzing and examining the issue of how high levels of fluoride in groundwater can cause serious health calamity. Although I am from New York and have been living, working, and going to school in New York my whole life, I think that in order to have an open mind and to understand how other people live it is important to look at problems and issues we are having, from their point of view. I feel it is important to compare and contrast similar issues or problems of the same subject in order to gain a broader view and a greater knowledge of the situation. By looking at Bangladesh, and then comparing their issues of fluoride in the groundwater and then comparing it to New York s levels of fluoride and the fluoride that is used in dentistry, I believe that an even greater understanding can be achieved, as well as a solution that can hopefully be implemented for all people to overcome this dilemma. In my research, I investigated why certain regions of Bangladesh were particularly being contaminated by fluoride. Although the levels of fluoride were in question and what I was testing, I had to first compare fluoride to another element that seemed to have caused issues and

9 health calamity as well, in order to have an idea of what the ratio of fluoride to that of other elements was. In order to determine how serious and high the concentration of fluoride was in the groundwater, I compared the element of fluoride to arsenic, since there were high levels of arsenic found in the same regions and groundwater. The groundwater in these regions of Bangladesh, which contain high levels of arsenic and fluoride, presents serious issues and health calamity. Much of the groundwater in Bangladesh is known to contain high levels of arsenic. Excessive arsenic intake can lead to arsenicosis, hyperkeratosis, and cancer. (WHO) The main levels that are most affected by high arsenic levels in the groundwater are the flood plains, table lands, and deltas. However, this problem has been going on for years, and there have been many studies done on this particular issue and solutions to this problem are still in progress. In recent times, another issue has come forth concerning a different region of Bangladesh, which are the hill tracts. These hill tracts have not been affected by high arsenic levels, however it has been discovered that there are high levels of fluoride. In Bangladesh, there are three main geomorphological regions that have especially been affected by arsenic contamination in the groundwater; which are flood plains, table lands, and deltas. These three regions, as well as the hill tracts, compose Bangladesh. It is considered that the flood plains and table lands, which contain Holocene sediments, are rich in arsenic bearing minerals. However, the hill tracts, which contain Pliocene sandstone, are not rich in arsenic bearing minerals and is mostly free from arsenic. Although these hill tracts are generally free from arsenic, one of my recent studies, alongside Dr. Alauddin, which included an analysis of approximately 150 groundwater samples from hill tracts areas, indicated that 20% of the samples possess fluoride levels that are greater than the World Health Organization regulated value.

10 These hill tracts are the only areas that are identified to have significant levels of fluoride in the groundwater. Whether or not the fluoride levels in groundwater can be the cause of a potential public health issue in Bangladesh is still in question. However, the recent findings suggest a strict monitoring of fluoride, as well as other ions in groundwater in Bangladesh, be initiated. (Alauddin, 2016) The main source of high fluoride intake for humans is through the drinking water, specifically in regions of the world where fluoride concentrations in groundwater and surfacewater are high. It is estimated that more than 200 million people worldwide rely on drinking water with fluoride concentrations that exceed the present WHO guideline of 1.5 mg L 1. (Manouchehr, 2008) The practice of adding fluoride to drinking water sources in order to help prevent tooth decay has remained a controversial topic since (Hileman, 2006) Due to potential health risks that high fluoride (F - ) intake levels can cause, the World Health Organization (WHO) set a guideline permissible value of fluoride to not exceed 1.0 ppm. In order to test the Chittagong Hill Tracts in Bangladesh for F- levels in the ground, surface water levels, and to compare F- with other ions found in this groundwater, 300 samples first had to be collected in Bangladesh, where they were then transported to the lab at Wagner College. The way these samples were analyzed was through the analytical technique of Ion Chromatography (IC). Ion chromatography is a form of liquid chromatography that is utilized to separate different ions based on their charge. This technique isolates all ions that are present in a certain sample so that each ion and element can be studied and analyzed. This technique is especially beneficial and useful when measuring the concentration of a particular ion in a water sample. Ion chromatography allowed for the most accurate screening the fluoride levels present in these 300 groundwater samples.

11 This analysis was done by taking a small volume of each sample, which is referred to as the mobile phase, and pumping the sample through a column of packed particles, which is referred to as the stationary phase. The time it takes for the ion to pass through is recorded and this is known as the retention time. The retention time of the ion depends on how it interacts with the column both physically and chemically. Once the samples were run through the Ion Chromatograph machine, the peaks of each ion were shown. A direct correlation can be seen between the concentrations of the ions moving through the column at a particular time and the concentration of a particular species in the sample solution. Once this was done the data on F- was compared to each of the other ions found in these water samples in order to see if there was any correlation. This was done so that the source of the high fluoride levels in the Chittagong Hill Tract region of Bangladesh could be determined. At the completion of this analysis and experiment, it was able to be concluded that there was no correlation between these elements which meant other bodies of water did not contaminate these bodies of water in Chittagong Hill Tracts. Due to the fact that there was no correlation between fluoride and the other ions, as seen by the low R-values, it can be concluded that there was no contamination between the seawater and the groundwater in Bangladesh. Since the high fluoride levels in the Chittagong Hill Tracts groundwater was not from an insurgence of water, this suggests that the sediments in the ground themselves leach out these ions, causing the fluoride levels to rise. With the exception of a few samples, the fluoride levels in most of the samples taken were within the WHO permissible guidelines, which is less than 1.0 ppm. Although high fluoride levels in groundwater is not ideal, it is not seen as a serious issue as of yet. However, some specific areas in developing countries, especially Bangladesh, need to be closely monitored in the coming years for a potential high level of fluoride. In the

12 future, more work needs to be done in order to identify the minerals that release the fluoride, thus causing higher and more dangerous levels of fluoride to be in the ground and surface water. Also the possible cause of the release of this fluoride needs to be studied within the coming years in order to be more able to prevent this from happening. The question now remains, how can we prevent consuming excess fluoride water from groundwater in order to avoid future health calamity and is there a way people from various regions around the world can obtain the benefits while still avoiding the risks and dangers of this element? Health is not valued till sickness comes - Thomas Fuller The consumption of fluoride by all people, especially the people who populate the Eastern regions of Bangladesh, is a more serious health calamity than most realize. The focus of the people in the Eastern regions of Bangladesh is important to study due to the fact that the levels of fluoride found in this area exceed the level that the World Health Organization allows in other regions of the world, New York to be specific. Although the levels of fluoride being added to New York water is monitored, any intake of fluoride can potentially cause critical health risks. Without educating oneself on the harms of fluoride intake, there is no way to prevent the illnesses and diseases that correlate to the consumption of this element. Intaking high levels and large amounts of fluoride by way of drinking water can cause many different health problems. The ingestion of this element can cause a problem known as fluorosis, which impinges the health of the teeth and bones in the body. According to the World

13 Health Organization Moderate amounts lead to dental effects, but long-term ingestion of large amounts can lead to potentially severe skeletal problems. (WHO, 2018) Although fluorosis of the teeth and bones are the most frequently seen health problems that are caused by high fluoride intakes, there are a list of other health concerns that is caused by fluoride intake, including cancer and human intelligence. Due to the fact that the element of fluoride is prevalently known and associated with use in the dental field, one of the most commonly seen health problems due to high fluoride intake is dental fluorosis. Dental fluorosis is a defect in the enamel of the tooth due to extreme fluoride intake, especially in the early development phases of enamel formation. The one major sign that someone is suffering with dental fluorosis is the enamel of that person s teeth are typically marked with void spaces, or noticeable elevated porosity. This defect in the enamel is a condition that is referred to as hypomineralization. Essentially, the enamel of the tooth surface is hypomineralized by the fluoride, thus weakening the teeth because this outer layer is slowly being destroyed. Although fluorosis can be cosmetically treated, the damage to the enamel is permanent. Common causes of fluorosis include: fluoridated drinking water (particularly during infancy), ingestion of fluoride toothpaste, use of fluoride tablets, and consumption of processed foods made with fluoridated water. (Fluoride Action Network) Since the major source of fluoride consumption is drinking water, the Environmental Protection Agency and World Health Organization must make sure all drinking water has a fluoride level no higher than 2.0 ppm, otherwise known as parts per million. However, once the fluoride concentration levels in drinking water is above 2.0 ppm, it becomes very difficult to remedy and maintain this problem since it is extremely hard and unaffordable to remove excess fluoride from drinking water. According to the World Health Organization The preferred option

14 is to find a supply of safe drinking-water with safe fluoride levels. (World Health Organization, 2018) It is also suggested by the American Dental Association People living in areas where naturally occurring fluoride levels in drinking water exceed 2 parts per million should consider an alternative water source or home water treatments to reduce the risk of fluorosis for young children. (American Dental Association, 2018) Finding an alternate water source in order to avoid dental fluorosis, and high fluoride intake of any kind, seems like a simple solution to this problem, however it is not necessarily a realistic one for people living in various regions of the world. In developing regions such as Bangladesh, the people living in this area do not have that option. In poor areas, it is often the case that the only source of water comes directly from the drinking, or groundwater, of that geomorphological region. This health problem particularly affects babies and young children until the age of eight because during these stages the teeth and enamel layers of the teeth are forming, so exposure to high levels and intake of fluoride can stunt the correct development. This is why it is suggested for young children ages eight or younger to only use a pea sized drop of toothpaste when brushing their teeth so that excessive fluoride is not being applied to the teeth or being swallowed. In addition to dental fluorosis, high fluoride levels and large fluoride intakes can also lead to skeletal fluorosis, which is a serious disabling bone disease. Skeletal fluorosis is usually caused by the ingestion of extremely large amounts and high levels of fluoride over a prolonged period of time. Although these circumstances that one would have to be under in order to suffer from this disease seem extreme, skeletal fluorosis is not rare and there are a great number of individuals that have to live with this condition. At times it is very difficult to distinguish skeletal fluorosis from other joint and bone diseases, which is why many believe that fluoride is not very harmful and is not the direct cause of this disease. One of the reasons doctors fail to detect

15 skeletal fluorosis is because the symptoms and appearance of fluorosis can closely resemble other, more commonly known, bone and joint diseases. (Fluoride Action Network, 2018) Other health concerns caused by high fluoride intakes cause a number of other serious health concerns. Another health problem that can result from consuming large amounts and high levels of fluoride are arthritic symptoms, such as joint pain, stiffness, and swelling, as well as fatigue. Bone fracture may also result due to the fact that the higher dosage of fluoride in drinking water and a large intake of this water can lead to greater chances of bone fracture. Other health problems that can result are cancer and human intelligence, which is mainly specific to children who are exposed to early fluoride toxicity. (Hoque, 2003) & (WHO) The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not. - Mark Twain Being in control of what one intakes into their own bodies is an extremely important concept that is a huge establishing factor of one s own health and well-being. A person s overall health is heavily dependent on what is being taken into the body. In order to maintain good physical, as well as oral, health it is critical to not only eat and drink healthy, nutritious foods and vitamins, but to also avoid all toxic chemicals, foods, drinks, and elements that can be a potential detriment to our health. The main thought that the majority of people seem to have when trying to live a healthy lifestyle is to exercise, watch your diet, and drink plenty of water. However, depending on the water source that people have access to and utilize to stay hydrated, they can actually be causing more harm to themselves than they might realize.

16 Due to the fact that in certain regions and cities of the world, New York to be specific, have fluoride purposely added to the drinking water, people do not have a say in what they are consuming when they intake tap water. According to a National Research Council The major sources of exposure to fluoride are drinking water, food, dental products, and pesticides. The biggest contributor to exposure for most people in the United States is drinking water. (National Academies Press, 2006) Fluoride is an element that is constantly up for dispute since it has potential health benefits, but also has many risk factors. The questions and concerns that pertain to the practice of adding fluoride to drinking water is a serious and prevalent problem that we deal with today in advanced places, such as New York, as well as developing regions, such as Bangladesh. This topic is extremely controversial because there are so many different viewpoints one may have about this issue. Some strongly believe that fluoride is beneficial to be consuming and the practice of adding this element to drinking water should be continued. Others have very strong views and arguments against this and believe that consuming fluoride can have precarious effects on people. And some are even torn and do not know fully which side to stand on, which can be due to the lack of knowledge and information they have on the issue. One reason why this issue is so controversial is because in certain developing regions of the world, Bangladesh to be specific, there are high levels of fluoride that is found in their groundwater, which has been proven to cause serious health calamity on the people in that area. However, in other, more advanced, regions of the world, for example, New York, the element of fluoride is added to the drinking water. The question is, even though the levels of fluoride being added are monitored by the WHO, is it safe to consume without putting ourselves at serious health risks. In general, anyone who is exposed to high levels or intake large amounts of fluoride put themselves at risk of being exposed to fluorosis, which is a severe condition caused by

17 excessive intake of fluorine compounds. What makes many people angry and upset is that if it is known that this element causes serious health adversity in regions that cannot control these levels, than why would the government purposely add this element to our drinking water? Another reason why this issue is of great importance, yet of great dispute, is because many people are not able to speak up about what they want and what they allow themselves to be consuming. A huge problem is that many people are not completely educated on this topic, and because of that do not realize how serious it can be. People should be informed and well aware of exactly what it is that they are consuming, and should have a say in whether or not the government continues this practice of adding fluoride to drinking water. Especially in developing regions of the world, where the populations struggle with poverty and since they are not very advanced with technology, medicine, and engineering, they do not even have their drinking water checked or monitored by any organization. People that live in developing regions of the world who do not have access to fresh, clean, unpolluted water, and do not have things such as water bottles that you can easily access from a grocery store, are forced to drink their groundwater. However the groundwater in certain areas can actually be considered as toxic, due to the astronomically high levels of fluoride, as well as other elements, chemicals, and waste. Of course, for people that live in the Eastern regions of Bangladesh, this issue is even more serious and can be more detrimental than it is for the people living in regions of New York. Although these two regions of the world differ greatly and are at very different advancing levels, the people can all relate to this problem, and people from both regions can relate in the fact that they do not have a say in whether or not they consume fluoride, and if so, how high of a level they intake.

18 The more specific we are, the more universal something can become. Life is in the details. If you generalize, it doesn't resonate. The specificity of it is what resonates. - Jacqueline Woodson This quote by Woodson can apply, not just to life as a whole, but to research, specifically. When researching a particular subject, discipline, or issue it is important to have information and facts to back up the claims one is making. One way to make research that is conducted on a particular issue resonated and understood for many people is to make sure that the information and facts included are specific. Without providing accurate and specific facts to your audience about the research you are doing, the information can be misunderstood, as well as allow for different interpretations of your research to be done by many. In my research up to this point I was mainly focusing on the different regions where naturally occurring fluoride can cause serious health problems and then examining whether or not fluoride is a safe element to be using in the practice of dentistry. However, this week I now plan to look into the specific amount of fluoride that can be consumed without causing harm to the patient. As I have previously discussed, there are many disadvantages and health problems that can be cause by having either too much or too little fluoride in one's system. However, in order to gain the benefits from fluoride, there are certain amounts that must be taken into consideration in the field and practice of dentistry when using fluoride as part of a patient s treatment. In the dental field there are two ways that fluoride can be administered to a patient: topically and systemically. Topical fluoride is used to strengthen the teeth by remineralizing the enamel and preventing decay. Topical fluoride can be delivered through the use of a variety of products, including toothpastes, mouthrinses, gels, and professionally applied fluoride treatments by the

19 dental hygienist. Systemic fluoride helps to strengthen the teeth by being integrated in the forming tooth structure through ingestion. Systemic fluoride can be delivered through water fluoridation and dietary fluoride supplements, such as drops, lozenges, and tablets. (ADA, 2017) Lack of fluoride could potentially cause health problems, however too much, as we know, can also lead to serious health calamity and concerns, which is why it is important to analyze and understand how much fluoride, specifically, should be used in the practice of dentistry. It is crucial that dental health care providers allow their patients to know the exact amount that will be used on them in the dental office, as well to inform their patients on how much fluoridated products to be using for their at home dental care and maintenance. The amount, or dose, of fluoride to be administered for each patient depends on two main factors; the age of the patient and how high of a risk the patient is to developing caries. Each patient has their own personal risks in terms of their oral health and developing dental caries. Patients who have good oral health and are not considered by their dental health care provider to be at high risk may not need a fluoride treatment and may just be advised to continue using fluoridated toothpaste and mouthrinses at home. However, if a patient comes in that the dental health care provider deems as high risk for dental caries, they might administer a professional fluoride treatment, as well as at home fluoride treatments and continuation of using fluoridated toothpastes and mouthrinses. Some patients have conditions, such as xerostomia, otherwise known as dry mouth, or other physical impairments that would make it difficult for said patient to keep up with good oral hygiene care. (AAPD, 2018) Age is perhaps the most important factor to consider when administering a patient with a fluoride treatment of any kind, especially a child. Fluoride that is delivered topically is not intended to be swallowed due to the fact that is is a treatment solely meant to strengthen the

20 teeth. When excess fluoride from these topical treatments is accidentally swallowed, slight cases of fluorosis can occur. Since children have the tendency to accidentally swallow toothpaste, mouthrinse, and fluoride treatment gels a lower dosage is recommended. Below is a chart provided by the American Dental Association and the American Academy of Pediatrics which shows the recommended fluoride supplement dose for patients from birth to 16 years of age. The water fluoride ion concentration is in measurements of parts per million, or ppm. (AAPD, 2018) As the chart above shows, younger ages only require a small amount and a small concentration of fluoride in order to gain the benefits of this element and to protect their teeth. The dental health care provider must make sure fluoride measurements are accurate for each patient based on their age and personal dental needs. If more fluoride than the necessary amount is used, fluorosis can occur. In these cases, the patient will usually experience nausea and vomiting until this element is out of their system completely. This same concept applies for at home use of fluoridated products for the patient. Fluoridated products such as toothpastes and mouthrinses is never to be swallowed. For children less than the age of 3, it is recommended that no more than a smear of rice-sized toothpaste should be used. For children between the ages of 3

21 and 6, it is recommended that no more than a pea-sized drop of toothpaste be used on the brush to help prevent the risk of fluorosis. Children 6 years and older should still only use pea-sized amounts of toothpaste, but can start to use fluoridated mouthrinses in very small amounts because it is known to help prevent dental caries. Home use of fluoride products for children should focus on regimens that maximize topical contact, in lower-dose higher-frequency approaches (AAPD, 2018) If these guidelines are followed closely than there should be a decreases in the risk of fluorosis in patients, as well as an increase in the benefit of the patient's teeth and oral health. Dental health care providers should strictly follow these guidelines in their practice, as well as inform their patients of these guidelines in order to prevent health risks. Critical thinking is not something you do once with an issue and then drop it. It requires that we update our knowledge as new information comes in. Time spent evaluating claims is not just time well spent. It should be considered part of an implicit bargain we've all made. - Daniel Levitin This quote directly mirrors the importance of evaluating claims when doing a research project of any nature or of any discipline. One cannot fully understand, advocate, or determine that certain research and concepts are valid until cases of policy are evaluated. By evaluating cases of policy, a better understanding can be gained. In light of my thesis the risks and benefits of fluoride in drinking water, there are many claims of policy that can be presented about this matter. This topic has remained controversial for over 70 years now due to the two main opposing sides on this issue. Water fluoridation has come under increasing scrutiny as health concerns, lack of efficacy in preventing tooth decay and ethical issues of administering chemicals via the water supply have surfaced (Dr. Joseph Mercola, 2018)

22 The current policy on fluoride addition of the drinking water in New York is that fluoride levels must be monitored and kept within World Health Organization guidelines. Currently the WHO set guideline permissible value of fluoride to not exceed 1.0 ppm, or parts per million. The government allows for this practice of adding fluoride to continue because it is believed that fluoride benefits the teeth and prevents dental diseases from occurring. The reason why it is added to drinking water is because, although fluoride is a naturally occurring element in water, it is not at a high enough level or concentration to actually protect the teeth. It is also believed that since fluoride is known to protect the teeth, it can lead to less oral health complications in general. Although fluoride can have its benefits and has been proven to help, rather than hinder, some people's oral health in some cases, the practice of adding fluoride in drinking water is failing because there are too many risks that directly correlate to the overconsumption of fluoride. In addition, many people are very unhappy with this practice because they do not have a say in how much fluoride they are consuming when they are drinking water. In the case of adding fluoride to drinking water, the risks outweighs the benefits. My claim of policy on this topic is the state of New York should ban the practice of adding fluoride to drinking water. The banning of this practice would be a great success for many reasons. One reason that the banning of this practice would be beneficial is because it would significantly lower the risk of health calamity. Since fluoride is known to be directly correlated to certain health issues, such as dental fluorosis, skeletal fluorosis, arthritic symptoms, bone fracture, cancer, and human intelligence, the risk of these diseases can be reduced substantially. Another reason why banning the practice of adding fluoride to drinking water would bring about a great outcome is because the people would have consent in what they are

23 consuming and the levels of fluoride they intake. This problem has been one of the hardest to resolve in past years and especially with the latest policy, which causes extreme controversy. If this practice does get banned, the people who still want to have fluoride levels within the WHO guidelines still can, however they would need their own at home filtering system which would add this element to only their drinking water. This way everyone can consent to what they are intaking into their bodies. The last main reason why banning this practice could produce a great result is because by preventing this addition of fluoride to drinking water, the risks are being reduced, however the benefits that this element presents can still be acquired. The addition of fluoride in drinking water in the state of New York is not necessary because it harms more than it helps. The concentration that is added to New York water is not significant enough to produce a beneficial outcome, thus fluoride in drinking water only puts people at risk of overconsumption.there is a much higher chance of gaining the benefits while avoiding the risks by implementing this policy because people are able to intake and get enough fluoride supplements with toothpaste, mouthwash, and fluoride treatments administered by the dental hygienists at their office. Although the claim of policy of banning the practice of adding fluoride to drinking water can produce many great outcomes and benefits, the New York State government will probably not change its policies, even if there is a solution and a reason that may be more beneficial and logical in terms of this current issue. Although banning this practice can potentially produce many great results, it is also important to understand why there are still some people, including the New York State government, who find it essential to have this fluoride supplement added to the drinking water. In order to understand the reasons why some believe fluoride is actually

24 beneficial, rather than harmful, in addition to completely analyzing this issue at hand, it is also crucial to look at the counterclaims that can exist on this issue. To effectively communicate, we must realize that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others. - Tony Robbins I picked this quote by Robbins for this week because I have finally gotten the chance to conduct my first interview and I feel that after this interview was conducted I gained a greater understanding and saw a different perspective of the topic I am researching. In order to gain a complete understanding and to fully grasp the viewpoints and values of others, we must first have an open mind and have a realization that the way we all perceive the world varies greatly, due to differences in culture, personal experience, principles, and knowledge. For the past couple of weeks I have been researching and expanding on my resources in order to understand and gain a complete view of the matter of whether or not fluoride in drinking water is safe, and if not should it then be used in the field of dentistry? This past week I had the please to interview someone that I have learned a great deal from over the past 5 years. Subject A. has much background knowledge about the topic at hand, in addition to insightful personal and professional opinions and views of this topic. After interviewing him, I was able to acquire a better sense of the true issue at hand in regards to fluoride in drinking water and its effect on dental practice. from somebody that has much knowledge about this current issue. This interview was conducted over the phone in 2 sessions. Subject: A

25 Profession: Scientist/ Professor Two sessions: Session 1: Friday Session 2: Sunday Session 1: Interview Introduction: I am studying and doing research on the benefits and risks that fluoride presents in the groundwater in developing regions of the world such as India and Bangladesh, and comparing those risks and benefits to that of the state of New York. I will then be applying these findings to see whether or not the use of fluoride is safe and beneficial in the practice of dentistry. First I just wanted to state that many people do not believe high fluoride intakes and exposure to high fluoride concentrations is that serious. I wanted to know where you stand and how serious you think this issue is? A.- It is not an issue here in NY, but fluoride content in water is very important and specific to health related issues. Too little fluoride and too much fluoride can both cause health problems. The World Health Organization, the WHO, allows fluoride levels of 1.5 ppm or milligram per liter. Water ove here is mostly surface water, including precipitation water, so mainly rain water or snow water. This New York water and the natural groundwater does not have enough fluoride in New York. If you do not have close to 1 ppm of fluoride intake then that can cause fluoride deficiency for tooth enamel which causes tooth decay. The fluoride is added in NY because there is actually not enough naturally occurring water so the WHO needs to supplement fluoride. In areas like Southern India, this issue is actually very serious though.

26 The enamel of the tooth is mostly made of calcium phosphate, but the fluoride actually replaces this enamel minerale with fluoride. The tooth then becomes brittle and breaks, or decays. The problem in Bangladesh is different. It is not as serious as of an issue as South India, but it might be a serious issue later on. In india it is a very serious issue because the fluoride in the groundwater over there more than 5 ppm and intaking that for a long time can cause toxic effect. Some areas in Southern India have fluoride levels from 10 ppm to even 38 or 40 ppm of fluoride in water, which is very high and unsafe. Fluoride in these regions is there naturally and is not in the water through treatment like New York water is. People in Bangladesh depending on groundwater as their source of drinking water and any excess fluoride can cause fluorosis. The work I have done in my profession was mostly concerned with arsenic levels in groundwater. But some sediments in Eastern Bangladesh, even if there is no levels of arsenic, there could still be fluoride. Most groundwater is still safe but a lot has fluoride higher than 1 ppm. If the fluoride is not naturally leaching out of rocks then it is safe. The fluoride levels might increase over time there. As far as water in New York, I think it is okay. I know that most water treatment in NY is okay and controlled. Geographically Bangladesh and regions of Eastern India share some similar minerals so it can potentially cause serious effect. Ground water might have fluoride due to intrusion of seawater. We found some high level, higher than 1 ppm, fluoride in some areas of Bangladesh, but it is not a serious toxic level yet. Has high fluoride intake levels affected you or your family directly? A.- No, I have no been directly affected by high fluoride levels and neither has my family or the people I know. I am from Bangladesh but have been living in the United States with my family for many years now, and the New York drinking water does not present any health threats right now. In Bangladesh it is not that serious of an issue and we have not come across much chemical

27 fluorosis. The data shows there is nothing to worry about and we don t known and have not seen any people affected by excess fluoride. Water has fluoride within permissible levels in Bangladesh. Our bodies do need some fluoride intake in order to prevent some health problems. Over there (Bangladesh) it is naturally occurring in the water. There is some fluoride that naturally occurs but it is within safe regions. My colleague works over there and he says that in the southern part of India it is a serious issue. Especially in the cities of Kerala and Karnataka. In india the problem is pretty serious. Globally there is 85 million tons of fluoride deposits, and 12 million tons are found in India alone. Fluoride concentration is very widespread and very serious. This is an important public health issues in 24 countries now, including india. The fluoride belt extends from Turkey to China and Japan. Natural fluoride deposits are found in India and affects lots of the population. In India 62 million people are affected by the fluoride contamination of water by fluorosis. It is very obvious India has serious fluoride issue from groundwater. In regards to the negative effects fluoride and high fluoride intakes can have on people who reside in a specific geographical area, in your personal and professional opinion is there any way to resolve these problems and what actions should be taken in order to do so? A.- As far as New York and Bangladesh are concerned, there is nothing to do right now since the levels of fluoride in the drinking and groundwater is not toxic. For the dangerous fluoride levels present in India, there needs to be a meeting with some officials for some form of filtration situation to be implemented. The people in this region are exposed to excess fluoride through groundwater and they have to remove it. Filtration is only way to fix this problem. The source of water over there is surface water, so if a filtration system is not implemented then the people have to change their source of water. They must seek out ground or surface water that has a lower fluoride level. First of all they have to look at the net source of all water and filter all

28 excess fluoride. The people can utilize rainwater or even they can search for groundwater that has low fluoride, but they have to be very selective. If this cannot be done then they have to introduce a filtration system. In my experience, the filtration systems I have used to remove arsenic, was also tested for removal of manganese and tested ion filtration system. This filtration system can remove low fluoride levels in Bangladesh, but I do not know how they would do that with higher levels found in India. In India the fluoride levels are from ppm and these levels are very serious and dangerous. The states I can mention that have been worst affected by high fluoride levels in groundwater is Andhra, which is the area that is the worst affected in south India. In the northern part of India the worst affected state is Gujarat. A few other states in India are moderately affected which are West Bengal, and a state called Assam. Assam has a border with Bangladesh, so if this state is already moderately affected by high fluoride levels then Bangladesh could be affected as well in the future. Bangladesh currently has a fluoride level of 1 ppm in the groundwater. Anything close to 1 ppm is a borderline case. If it goes over 1.1 or 1.2 ppm then the fluoride levels should be looked at. If Bangladesh eventually becomes moderately affected as well then intervention has to be taken. Session 2: Interview Introduction: To continue this interview and gain a greater understanding of this issue and your experiences, as well as your personal and professional opinions and viewpoints, I will be asking a few more questions. Being that you have first hand seen the effect of high fluoride in the ground water of Bangladesh, and have also first hand seen how fluoride is added to our New York drinking water, How do you feel about fluoride being added to the drinking water of New York,

29 when naturally occurring fluoride in drinking water has caused problems in other regions, like Bangladesh? A.-Fluoride is essential for the body. If you do not have fluoride it can cause problems with tooth decay and that is why fluoride is added in New York. I think this practice is okay in NY. Even toothpaste and mouthwash have fluoride and since these products have it, people can be exposed with this as well. This is all within permissible value to prevent tooth decay. Water that is treated in New York is not groundwater. There is no natural fluoride so they supplement because it is needed and essential for people to have. But in Bangladesh and India that is separate issue. The fluoride in the water comes from bedrock and sediments. Over there it is a toxic issue, so they have to remove it, especially in India. Right now Bangladesh has the best situation because they do not fluoridate or treat water, but they have naturally occuring fluoride at 1 ppm or less. The main problem in Bangladesh now is high levels of other toxic elements like arsenic. Here in New York it is okay and it is not too much. Fluoride is actually essential. Keep in mind toothpaste or mouthwash has fluoride and that is okay for people to consume. Based on your professional and personal opinion and based on your experiences, Do you think it is safe to use fluoride in the field and practice of dentistry? A.- I m not sure because I do not have much of a background in dental materials and what is used in the dental field. I would have to see the level of fluoride in toothpaste and mouthwash, but I assume it is a very little amount. I think it is probably safe, but the reason fluoride is added to water in New York is because water is something all people drink. Fluoride levels in this water is low and since it can also be dangerous for people to be underexposed to fluoride intake it is supplemented in the water. Not everyone uses mouthwash or goes to dentist so adding to fluoride to water is supplemented for all people, and that way they can ensure nobody is underexposed. I think this practice is still good. The water is tested and monitored so we can get

30 good amount and level. All people in New York are exposed to good levels of fluoride supplements. An example to compare is table salt is iodized so people can get sufficient iodine intake, so this is basically the same thing with the water. The people are at least getting the essential amount needed to prevent tooth decay. Do you think that those who still want to gain some of the positive effects fluoride could have on their oral health can gain it through use of different dental materials, such as fluoridated toothpaste, mouthwash, and the fluoride treatments administered from their dental health care provider? A.- I cannot say totally about the use of excess fluoride. In New York fluorosis is rare, and most likely does not happen. Toothpaste and mouthwash fluoride levels is still not going over the WHO permissible guidelines and is still not toxic. This may vary from person to person. But I think for the general population it is a good idea What do you wish to see in the future? How do you think we can solve this problem and what actions do you think need to be done? A.- I think there is nothing to worry about in New York and that it is a good idea to continue to fluoridate the water here. This is my opinion. Just look at WHO level and what is needed. For tooth health and tooth decay we need fluoride. We have the best quality of water here. Water in Bangladesh and Southern India is bad in comparison to New York, and to even other areas of the U.S., but New York has the best water. New York has excellent water quality. In India and Bangladesh the surface water is bad. This is due to much Indiscriminate dumping of waste which is not very controlled. The surface water and groundwater is contaminated by natural sources. There is no industrial issue over in those regions, fluoride naturally contaminates the water so they have to actually filter it. In India especially, they need to remove all contaminants and look for groundwater that is safe. There is a lot of groundwater that is safe and free from all elements

31 in Bangladesh. Excess of anything and any element is always toxic. Even essential trace element that are too high over the guidelines can cause health effect. Bangladesh has to be on guard about this potential problem and in India this is already a serious issue that needs to be fixed. Efforts need to be made. They have to purify the water over there. It is two very different worlds. In New York, we are okay but over there it is not okay and they face all kinds of issues. Also this is not just in India and Bangladesh, fluorosis is an issue in at least 24 countries. Even here in New York there is a possibility that there may be some fluoride in groundwater that is naturally occurring. This groundwater must also be tested and monitored. At completion of conducting this interview, I realized how much I gained from speaking to someone who has great knowledge about this topic, as well as a broad perspective of the effects of fluoride. Although what A. said regarding fluoride differed from what most of my scientific resources states, I think it was more beneficial that I was able to gain an understanding of both sides of this controversial topic and have a greater understanding of the true issues at hand. I think it's very important to have a feedback loop, where you're constantly thinking about what you've done and how you could be doing it better. I think that's the single best piece of advice: constantly think about how you could be doing things better and questioning yourself. - Elon Musk I picked this quote for this week s writing because I felt I strongly related to it, especially at this point in my writing experience and research. Throughout my writing and research experience thus far, I have come to realize and understand the importance of not only gathering information, but analyzing that information and asking myself how can I better apply this information and research to a bigger problem to provide possible solutions. Although I feel I

32 have accomplished a lot with my research journey, there are still questions that need to be answered, and work that has to be done before my research is fully completed. Throughout my research and writing process for this course, after each week I constantly questioned what more I should do for the coming weeks and how I can better my writing, research, and problem solving skills. I feel that one of the most enlightening experiences I had during my research so far was conducting my interview with Subject A. This source really helped to provide me with some helpful insight, as well as allowed me to start questioning and viewing counterclaims of my topic. One of the things that I felt I needed for this research to feel more complete and accurate was to try to do another interview with someone who had been a bit more personally affected by the issue of fluorosis. It was hard to find someone that I could interview, especially being that many people who are seriously affected are from developing regions of the world. However, with some help, I was able to conduct a phone interview with Subject B. Although I do not personally know Subject B, Subject A from my first interview helped to put me in contact with this person, which was very helpful since I felt I would be able to obtain an even broader view of this issue at hand. Subject B has a more personal experience with the issue of fluorosis, due to the fact that his niece was exposed to higher fluoride intakes as a baby. Subject B currently lives in New York, however is originally from Assam, which is a state in India that is known to be moderately affected by fluoride levels in groundwater. Subject B frequently visits Assam still to see his family. In my interview with Subject B, I was able to gain an understanding of another view of this issue at hand. This interview was conducted over the phone in 1 session. Subject: B

33 One session: Friday Interview Introduction: I am studying and doing research on the benefits and risks that fluoride presents in the groundwater in developing regions of the world such as India and Bangladesh, and comparing those risks and benefits to that of the state of New York. I will then be applying these findings to see whether or not the use of fluoride is safe and beneficial in the practice of dentistry. First I just wanted to state that many people do not believe high fluoride intakes and exposure to high fluoride concentrations is that serious. I wanted to know where you stand and how serious you think this issue is? A.- I think that this issue can have certain health problems on children who are exposed to high levels of fluoride. Most of my family still lives in and around Assam. Growing up I never knew or understood that high levels of fluoride in the water was dangerous. It is easy to just drink the water that comes from the groundwater in India. I have been living in New York for many years now and after I met Subject A and he informed me about the certain health calamity higher fluoride intakes can cause in certain areas, especially my home in Assam. Growing up, I never faced many problems because of the drinking water. People who had problems that could have been related to this higher intake of fluoride did not always relate their health problems to their water drinking source. However, living in New York for over the past 25 years I met many very intellectual people who have made me aware of this issue. A few years ago my niece, Aasya, was starting to have some trouble reaching some developmental milestones. My brother and his wife took Aasya to some doctors but they were unable to determine exactly what the cause of this delay was. I talked to some people I know here in the United States about this issue my niece

34 was having, including Subject A. It was then that I realized the intake of fluoride could be a possible cause of this intellectual and milestone setback. I told my brother about this and he then made the effort to change Aasya s source of water from the groundwater to a source that was known to be more safe. The doctors that saw my niece said that sometimes some children just have delayed milestones, but that a lot of the time they do eventually meet those milestones. This delay could be related to a number of things. Thankfully, after some time Aasya did start to hit her milestones the way her doctors had expected. Although Aasya s delay could have been from a number of things, I started to think that it was was not until after we had changed Aasya s water drinking source that she had started to reach her milestones. I am just happy that she is progressing the way that the doctor s had hoped and is healthy and happy now. However it does make me question if this fluoride in the drinking water back over there can cause serious health problems or not. (My next question was going to be Has high fluoride intake levels affected you or your family directly? but Subject B already included his experience with that in my first interview question to him.) In regards to the negative effects fluoride and high fluoride intakes can have on people who reside in a specific geographical area, in your personal opinion is there any way to resolve these problems and what actions should be taken in order to do so? A.- It is hard for me to say a definite answer to this question. My whole family and myself included have resided in Assam for many years and have not had health problems because of the drinking water. However, I now know that this state is particularly known to have high fluoride levels and can potentially cause health problem in people and children over there that consume this water. My niece, on the other hand, did have delayed milestones and once her source of water was changed she then started meeting these milestones. But, her doctors did not say that

35 this was the definite reason she was no longer being delayed. I am not sure if this is just a coincidence since this delay in milestones does happen to some children or not. I think perhaps over there (Assam) should be studied more in order to see how serious these issues related to fluoride actually are so we can figure out if any action should be taken. Being that you now know what the effect of high fluoride intake in the ground water of regions such as Bangladesh and India could potentially cause, and have also first hand seen how fluoride is added to our New York drinking water, how do you feel about fluoride being added to the drinking water of New York, when naturally occurring fluoride in drinking water has caused problems in other regions, like Assam, India? A.- At first I was a bit skeptical myself about the fluoride addition to New York water after finding out fluoride can have some negative effects on health and after the problems my niece was having that could have been caused by fluoride intake. However, after speaking to some people, including Subject A, I realized that fluoride also provides positive effects as well. Since in New York it is monitored I think it is okay because it is at a good level. Back over there it is not monitored which is what may be causing some of the health problems. Based on your personal opinion and based on your experiences, Do you think it is safe to use fluoride in the field and practice of dentistry? A.- I do not have much knowledge about fluoride and its use in dentistry so I cannot say a definite answer to this. I think that if it is monitored and if it is determined to be safe then this is one of the positive effects that fluoride has. Do you think that those who still want to gain some of the positive effects fluoride could have on their oral health can gain it through use of different dental materials, such as fluoridated toothpaste, mouthwash, and the fluoride treatments administered from their dental health care provider?

36 A.- I cannot say for sure because I do not know much about fluoride and its use in the dental practice, but if it is monitored by health care professionals then I think it is okay. Also I have learned that some fluoride is actually necessary so if it is for a positive health effect then I think it is okay to use. What do you wish to see in the future? How do you think we can solve this problem and what actions do you think need to be done? A.- I think that if over there (Assam) in India is really having concerns with the level of fluoride in the water it should be monitored more closely so there are not anymore health problems due to high fluoride intake in the water. For my niece, I think that changing her water drinking source might have helped her problem and stopped the delay from continuing, but I cannot say this for definite. But, monitoring the water over there cannot hurt. At completion of conducting this interview, I felt I gained a greater understanding from speaking to someone who had a more first hand and personal experience with this issue. The fact that him and his family are all originally from Assam, India which is one of the states that is well know to have moderate levels of fluoride in their drinking water, helped me to feel that I had an accurate primary source to refer to when going back and analyzing the rest of my research that I had already conducted and plan to conduct. Although it is not definite that changing the drinking water source of Subject B s niece helped her problem, or reversed the possible effects higher intake of fluoride could have caused, it is most definitely something to consider. Also at the completion of this interview, I realized that there are certain points to my original claim that seem to be true, and others that I need to look into and question more. What I now plan to look

37 into more thoroughly is if fluoride use in dentistry really does propose a very positive health effect on people or not. Research is creation of knowledge which leads to new and efficient solutions for the society. - Shiv Nadar This quote by Nadar is very relatable for me during this week of my research journey. At this point in the semester I feel I am finally gaining enough background information and research to start applying my findings in order to solve my original, bigger problem. I have questioned whether or not fluoride in drinking water is a safe or unsafe practiced and looked at different regions of the world to help me have a better understanding if fluoride is, in fact, safe to use in the practice and field of dentistry. Now that I have gained much information and understanding about the fluoride levels in drinking water, looked into the health effects high fluoride intakes can cause, as well as conducted 2 interviews, I feel that I am ready to take this information and look at it on a greater scale to help me determine if fluoride use is beneficial in the practice of dentistry. After comparing the drinking water of New York to that of developing regions of the word such as Bangladesh and India, I came to realize that although too much fluoride intake can cause negative health effect, too little fluoride can also have adverse effects on dental health. Fluoride is a naturally occurring element in the earth, and is also known to be naturally occurring in the human body. Fluoride is an important and essential mineral that forms a main constituent of the bones and teeth. (Dove Med, 2016) This element actually plays a very important role in providing protection of our teeth and some of our vital organs. Fluoride maintains a certain level of strength and structure throughout our bodies, which is not only good for our bones, but also

38 helps to protect our internal organs, specifically our brain, spine, heart, and lungs. Without any fluoride we risk weakening our overall health. (Dove Med, 2016) Although fluoride presents many great effects for our bones and strength of our bodies, the greatest health advantage that fluoride provides is its aid in the protection of our oral health. The effect fluoride can have on oral health, when monitored correctly, can actually lead to great benefits and outcomes. Fluoride strengthens the enamel of the teeth and provides the tooth with the essential minerals that may be lost over time, thus preventing decay and dental caries. Fluoridated water supplies and toothpaste are so effective that that they have been credited as part of the dramatic drop in tooth decay and cavity occurrence that has taken place over the past 50 years. (Chemical Safety Facts, 2018) In New York, because the level of fluoride in the drinking water is monitored, it is not only safe to consume, but also beneficial and recommended. The WHO sets permissible fluoride guidelines for different states so that the risk of high intake and excess fluoride in the drinking water is avoided. Just for an example, our New York fluoride level in the drinking water is slightly higher than that of a place like Floride. This is because Florida is much more hot and humid, leading to more frequent thirst, and more consumption of water by the people that live there. These are factors that are considered by the World Health Organization so that health calamity is avoided, and also so that the greatest benefit can be achieved. Water fluoridation has actually produced so many great benefits over the past 50 plus years that the CDC actually listed community water fluoridation as one of the top 10 greatest public health achievements of the 20th century. (Chemical Safety Facts, 2018) In the practice and field of dentistry, the use of fluoride is essential and beneficial for patient care. Without good daily oral hygiene and regular dental visits, teeth become more

39 vulnerable to caries. (ADA, 2007) Besides brushing 2-3 times a day and flossing, the use of fluoridated toothpastes, mouthwash, and at home fluoride treatments is a good way for people to maintain healthy teeth, gums, and overall oral health in between dental visits. People should see their general dentist and get a dental cleaning every 6 months in order to prevent possible oral health problems. If a dental health care provider notices a particular person is at moderate-tohigh risk of developing caries, then a professional fluoride treatment can be administered at the dental office. The fluoride preparation used in the dental office is a much stronger concentration than that in toothpastes or fluoride mouthrinses that may be available in a store or at a pharmacy. (ADA, 2007) This professional treatment can significantly decrease the chances of that patient getting dental caries or decay in the future. Professionally administered fluoride treatments can be given every 3, 6, or 12 months depending on the oral health of each patient. (ADA, 2007) The use of fluoride in the dental field is very helpful and has been proven to yield many positive results for the patient's overall oral health. Watch every detail that affects the accuracy of your work. - Arthur C. Nielsen This quote by Nielsen strongly relates to the writing style that I have been working on and trying to improve throughout the course of this semester. As the course of this semester progressed, I realized and started to understand how important specific details are when writing a thesis. The specifics and details dealing with the claims I am making allows my audience to believe and understand that I am a reliable source and that the information I am providing is accurate. In order to provide information and research that is valid and accurate, close attention to detail must be obtained. As I have previously discussed, there are many benefits to consuming and using fluoride in the practice of dentistry. However, too much or too little fluoride can provide potential serious

40 risks and health calamity, which is why it is very important for dental health care provided to be aware of how much fluoride is permissible for each of their patients in order to provide the benefits but avoid the risks this element can provide. In the practice of dentistry fluoride therapy is administered topically to patients. The specific needs and the age of the patient are the main factors that determine the amount of fluoride that is administered to each individual patient. It used to be believed by experts in the dental field that fluoride was only beneficial in strengthening teeth that were still growing and developing. This is why fluoride therapy treatments were only done on children and why all fluoridation efforts were mainly focused on children s teeth. However, new research now shows that fluoride treatments can be beneficial for people of all ages. Studies now show that topical fluoride the kind in toothpastes, mouth rinses and fluoride treatments helps fight decay in people of all ages. (Colgate-Palmolive Company, 2018) In the case of administering fluoride therapy treatments to adults, similar guidelines to that of children are followed. Although fluoride is know to particularly help and strengthen the developing teeth of children, it is also known to strengthen the teeth and prevent dental caries in adults patients and elderly patients. It is the case that most adults who live in regions with monitored fluoridated water, that brushing with fluoridated toothpaste and using the fluoridated water is actually enough to gain the benefits of this element while avoiding the risks. However, patients, particularly elderly patients, who suffer from certain conditions such as dry mouth, high risk for caries, and gingival recession, professionally administered fluoride therapies may be required. (Colgate-Palmolive Company, 2018) For most healthy adults, there is no real need for professionally administered fluoride therapy treatments, due to the fact that there is no reason to expose a patient to excess fluoride

41 when it is not needed. In cases where a patient is at high risk for developing caries then professional and at-home fluoride therapies may be utilized. According to the American Dental Association Adults should have 2.26% fluoride varnish applied for both coronal and root caries. Varnish should be applied at least twice per year for root caries prevention. (BDA, 2014) The chart from the Journal of the American Dental Association provided below shows the clinical recommendations for use of professionally applied or prescription-strength, home-use topical fluorides for caries prevention in patients at elevated risk of developing caries. (JADA, 2013) As the chart above shows, for patients older than 18 years of age, fluoride therapy applications are to be determined by the dental healthcare professional. Since not every adult necessarily needs fluoride therapies in the way that children do, each patient is to be treated and